<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">


    <div class="form-group hide">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_drug_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_drug_id" data-rule="required" data-source="presentationdrug/index" class="form-control selectpage form-control" name="row[presentation_drug_id]" type="text"  value="{:$_GET['cid']}">
        </div>

    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Dose_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-dose_number" class="form-control form-control" name="row[dose_number]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Dose_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-dose_unit" class="form-control form-control" name="row[dose_unit]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Number_of_units_in_the_interval')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-number_of_units_in_the_interval" class="form-control form-control" name="row[number_of_units_in_the_interval]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Definition_of_the_time_interval_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-definition_of_the_time_interval_unit" class="form-control form-control" name="row[definition_of_the_time_interval_unit]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Date_and_time_of_start_of_drug')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-date_and_time_of_start_of_drug" class="form-control form-control" name="row[date_and_time_of_start_of_drug]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Date_and_time_of_last_administration')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-date_and_time_of_last_administration" class="form-control form-control" name="row[date_and_time_of_last_administration]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Duration_of_drug_administration_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-duration_of_drug_administration_number" class="form-control form-control" name="row[duration_of_drug_administration_number]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Duration_of_drug_administration_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-duration_of_drug_administration_unit" class="form-control form-control" name="row[duration_of_drug_administration_unit]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Batch_lot_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-batch_lot_number" class="form-control form-control" name="row[batch_lot_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Dosage_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-dosage_text" class="form-control  form-control" rows="5" name="row[dosage_text]" cols="50"></textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pharmaceutical_dose_form_free_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pharmaceutical_dose_form_free_text" class="form-control form-control" name="row[pharmaceutical_dose_form_free_text]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pharmaceutical_dose_form_termid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pharmaceutical_dose_form_termid_version_date_number" class="form-control form-control" name="row[pharmaceutical_dose_form_termid_version_date_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pharmaceutical_dose_form_termid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pharmaceutical_dose_form_termid" class="form-control form-control" name="row[pharmaceutical_dose_form_termid]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Route_of_administration_free_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-route_of_administration_free_text" class="form-control form-control" name="row[route_of_administration_free_text]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Route_of_administration_termid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-route_of_administration_termid_version_date_number" class="form-control form-control" name="row[route_of_administration_termid_version_date_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Route_of_administration_termid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-route_of_administration_termid" class="form-control form-control" name="row[route_of_administration_termid]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_route_of_administration_free_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_route_of_administration_free_text" class="form-control form-control" name="row[parent_route_of_administration_free_text]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_route_of_administration_termid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_route_of_administration_termid_version_date_number" class="form-control form-control" name="row[parent_route_of_administration_termid_version_date_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Parent_route_of_administration_termidg')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-parent_route_of_administration_termidg" class="form-control form-control" name="row[parent_route_of_administration_termidg]" type="text">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
